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Pulsatile Tinnitus Survey Consent to Participate

You are invited to participate in a web-based online survey on pulsatile tinnitus. This is a research project being conducted by Karl Meisel, Matt Amans and Alvin Lau, physicians at the University of California San Francisco. It should take approximately 10 minutes to complete.

PURPOSE:
We are conducting this survey to better understand the impact that pulsatile tinnitus has on people's lives in terms of depression, anxiety, and function. We hope that this information will help guide us in terms of providing better care for our patients and raising awareness of pulsatile tinnitus as an illness.

SURVEY QUESTIONS:
The survey questions will ask you about tinnitus symptoms and daily functioning along with depression and anxiety symptoms. There are serious questions included in the survey such as asking about suicidal thoughts. We are not monitoring the responses to this survey and are unable to respond to help address these issues. Therefore, if you are experiencing suicidal thoughts or a high degree of distress please seek help with your local physician, such as your primary care physician.

PARTICIPATION
Your participation in this survey is voluntary. You may refuse to take part in the research or exit the survey at any time without penalty. You are free to decline to answer any particular question you do not wish to answer for any reason.

BENEFITS
You will receive no direct benefits from participating in this research study. However, your responses may help us learn more about how pulsatile tinnitus effects peoples lives.

RISKS
There is the risk that you may find some of the questions to be sensitive.
OR
There is the risk that some questions may cause emotional discomfort.
OR
Some of the survey questions ask about pulsatile tinnitus, depression, and anxiety symptoms, which may be distressing to you as you think about your experiences.
OR
The possible risks or discomforts of the study are minimal. You may feel a little uncomfortable answering personal survey questions.

CONFIDENTIALITY
Your survey answers will be sent to a link at RedCap where data will be stored in a password protected electronic format. RedCap does not collect identifying information such as your name, email address, or IP address. Therefore, your responses will remain anonymous. No one will be able to identify you or your answers, and no one will know whether or not you participated in the study.

CONTACT
If you have questions at any time about the study or the procedures, you may contact my research supervisor, Dr. Karl Meisel via phone at 415-353-8897.

If you feel you have not been treated according to the descriptions in this form, or that your rights as a participant in research have not been honored during the course of this project, or you have any questions, concerns, or complaints that you wish to address to someone other than the investigator, you may contact the University of California San Francisco Institutional Review Board at 3333 California Street, Suite 320
San Francisco, California 94143-0962, or IRB@ucsf.edu, 415-476-1814.

ELECTRONIC CONSENT: Please select your choice below. You may print a copy of this consent form for your records. Clicking on the "Agree" button indicates that

• You have read the above information
• You voluntarily agree to participate
• You are 18 years of age or older

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